Calais Dermatology Associates
Please present ALL insurance cards to the receptionist. If patient is a minor, and you are not the legal guardian, please ask receptionist for minor paperwork. Patient Information: Please Complete All Fields
Using Legal Names of the Parties Involved.
Name: (First) (MI) (Last)
D.O.B: Age: Sex: □ M □ F Status: □Single □Married □Divorced □Widowed
Mailing Address: Race:
City: State: Zip: Social #:
Cell: Home: Email: _
Emergency Name and #______Relationship:______
Referring Dr: Town: _
Pharmacy: Street/Town: _
Our current computer system sends appt. reminders by text or email. Would you prefer?
□ Text □ Email □ Neither
Due to increasing costs of stamps and our computer system, we can now send billing statements to your email. Please specify your preference. □ Email □ Mail
Insurance Info:
Primary Ins.: Grp # ID#
Policy Holder: D.O.B:
Patient Release: Must be signed by patient if 18 or over, or by legal guardian if patient is under 18
I certify that the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare) for the purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider.
I certify that I hereby authorize Calais Dermatology, its providers and staff to provide my minor child in my absence with examination and basic treatments for which additional consents are not required. I understand as the legal guardian of this child I am required to be physically present to consult with the provider on many procedures which require separate consent. I understand additional written consent may be necessary for certain types of procedures and that the legal guardian must be present for such consent.
______
______
Patient/Guardian Signature Date
Patient Name:
Patient/Guardian Signature: Date:
By signing this form I understand and agree to abide by Calais Dermatology’s office policies stated on this form.
Insurance Card Policy:
We require you to confirm that your insurance is current at each office visit. New patients or existing patients with a change in their insurance information must provide a valid insurance card or temporary print out at the time of the visit. Should you be unable to produce this documentation, you may pay in full at the time of service and submit the claim to your insurance carrier for reimbursement. I understand that by signing below I am
responsible for notifying Calais Dermatology of any changes to my insurance.
Insurance Referral Policy:
If my insurance plan requires a referral, I understand that it is my responsibility to obtain an updated referral from my Primary Care Provider and to make sure that Calais Dermatology has the referral before my visit. I understand that it is my responsibility to keep track of the number of visits I have used on my referral and the expiration date of my referral and to obtain new ones as needed.
Co-Payment Policy:
Co-payments are due and collected on the day of my or my family’s appointment.
Account Balances:
I am responsible for the timely payment of my account balances, co-insurance and deductibles. All balances are due in full within 30 days of my first billing. Any balance left unpaid after 90 days, without any attempt at resolution, will be considered delinquent and may be submitted to a collection agency. If I am having financial difficulty, I will call the billing office to discuss a payment plan.
Minor Patients:
A legal guardian must accompany children under the age of 18 to their initial appointment so that the proper forms can be filled out and signed. Follow up visits do not require a guardian’s presence, unless a procedure is being performed that requires a signed consent form.
College Students:
If you are a college student on your parent’s insurance plan, your insurance company will require a form to be completes confirming your student status. These forms are mailed to your home address and must be completed and returned within 30 days. If these forms are not returned within the time frame, you will be financially responsible for all charges incurred.
Insurance Requests:
Your insurance company will periodically require a form to be completed concerning coordination of benefits or whether you have other insurance coverage. These forms are mailed to your home address and must be completed and returned within 30 days. If these forms are not returned within the time frame, you will be financially responsible for all charges incurred.
Appointment Cancellations:
If I am unable to keep my scheduled appointment, I will call Calais Dermatology to cancel or re-schedule my appointment. Regular appointments require 24-hour cancellation notice. Cosmetic and Surgical appts require 48-hour cancellation notice.
Calais Dermatology Associates HIPAA Policy
Patient Name:
HIPAA Policy:
Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act. This Federal Law prohibits any staff member of Calais Dermatology from discussing appointments, medication, test results or treatment plans with anyone other than the patient. Often, this causes difficulty for some patients who would like family members or caretakers to obtain information for them. This becomes especially important if your spouse assists with making appointments for you or if you are an adult college student away at school and your parents assist with prescriptions and appointments.
If you would like to permit someone to discuss your medical condition, confirm appointments or obtain results for you, please indicate their name(s) below. Only these individuals will be provided with information. Should you wish to update the names provided below, please ask the receptionist for a HIPAA Form.
Name of Individual (please print) Relationship to Patient
1.
2.
Please check off which of the following methods we may use to contact you regarding your appointments and medical and billing information.
Leave a Message Regarding Appts. Med. /Billing Info
Home Answering Machine? Office Voicemail?
With Another Person? Sent through mail?
Sent via e-mail? _
Cell phone?
Patient/Guardian Signature:
Date:
I acknowledge and understand the above HIPAA policies and have received a copy of the practice’s
Notice of Privacy Practices related to the Health Insurance Portability and Accountability Act of 1996 and HITECH
policy.
Calais Dermatology Associates, 5220 Flanders Drive, Baton Rouge, LA 70808 225‐766‐5151
History and Intake Form
Reason For Visit:______Patient’s Name:______
Past Medical History: (please check all that apply)
qAnxiety
qArthritis
qAsthma
qAtrial fibrillation
qBone Marrow
qTransplantation
qBreast Cancer
qColon Cancer
qCOPD
qCoronary Artery
qDisease
qDepression
qDiabetes
qEnd Stage Renal
qDisease
qGERD
qHearing Loss
qHepatitis
qHigh Blood pressure
qHIV/AIDS
qHigh Cholesterol
qThyroid Problems
qLeukemia
qLung Cancer
qLymphoma
qProstate Cancer
qRadiation Treatment
qSeizures
qStroke
qNONE
Other
Past Surgical History: (please check all that apply)
qAdenoids/ Tonsillectomy
qAppendix (Appendectomy)
qBladder (Cystectomy)
qBreast Biopsy
q Breast: Lumpectomy (B, L, R)
q Breast: Mastectomy (B, L, R)
q Colon (Colectomy): Colon Cancer/Diverticulitis/Inflammatory Bowel Disease
qGallbladder: (Cholecystectomy)
qHeart: Coronary Artery Bypass Surgery
qHeart: Biological/ Mechanical Valve Replacement
q Heart: PTCA
q Joint Replacement Hip/Knee: (B, L, R)
q Kidney Biopsy (Nephrectomy)
qKidney Removed
qKidney Stone Removal
qKidney Transplant
q Liver: Hepatectomy
q Liver Transplant
q Liver: Shunt
q Ovarian Cyst
q Ovaries: Endometriosis/ Tubal Ligation
q Pancreas: Pancreatectomy
q Prostate Biopsy or Cancer
q Prostatectomy: TURP
q Rectum: Low Anterior Resection/APR
q Skin: Biopsy/ Melanoma / Basal Cell Carcinoma/ Squamous Cell Carcinoma
q Spleen (Splenectomy)
q Testicles (Orchiectomy)
q Uterus (Hysterectomy): Fibroids/ Uterine Cancer/Cervical Cancer
qNONE
Other
Skin Disease History: (please check all that apply)
q Acne
q Actinic Keratoses
q Asthma
q Basal Cell Skin Cancer
q Blistering Sunburns
q Dry Skin
q Eczema
q Flaking or Itchy Scalp
q Hay Fever/Allergies
q Melanoma
q Poison Ivy
q Precancerous Moles
q Psoriasis
q Squamous Cell Skin
q Cancer
q NONE
Other
Do you wear Sunscreen? q Yes q No
If yes, what SPF?
Do you tan in a tanning salon? q Yes q No
Do you have a family history of Melanoma? q Yes q No
*excluding Basal and Squamous Cell Carcinomas*
If yes, which relative(s)? Have you received your Flu Shot this year? q Yes q No
Have you received a Pneumonia shot in the past? q Yes q No
Medications: (Please enter all current medications and dosage)
Drug Allergies: (Please enter all allergies)
Social History: (Please check all that apply)
Cigarette Smoking:
q Currently Smokes
q Former Smoker
q Never smoked
Alcohol Use:
q None
q Less than 1 drink per day
q 1-2 drinks per day
q 3 or more drinks per day
Family Medical History: (mother, father, brother, sister or child) indicate with
1st letter. Ex: Mother has heart disease _M_
Heart Disease
High Blood Pressure
Cancer
Diabetes
Stroke
Other
Are you currently experiencing any of the following? (Please check yes or no for the following)
Symptom: YES NO
Hair LossRash
Problems with scarring
Problems with bleeding
Other Symptoms:
ALERTS: (please check all that apply)
q Allergy to Adhesive
q Allergy to lidocaine
q Allergy to topical antibiotics
q Artificial heart valve
q Artificial joint replacement
q Blood thinners
q Defibrillator
If interested in cosmetic products and services, please mark or circle on diagram your areas of concern:
Other, please specify: ______
Email for promotions and specials: ______
q MRSA
q Pacemaker
q Require antibiotics prior to a surgical procedure
q Rapid heartbeat with epinephrine
q Are you pregnant or currently trying to get pregnant?